Jamie Elliott

25 Apr 2017 · Coroner Edwin Buckett · London Inner (North)

The coroner's concerns

1. lack of implementation of Serious Incident Review recommendations
“Evidence was given by the Trust that a Serious Incident Review had identified areas of concern but no changes had been implemented and it 2 was not clear when any of the suggested changes would actually be made”
2. failure to contact external providers when considering compulsory detention
“Mental health clinicians from the Trust should be required to contact external providers of mental health services, if possible, when a patient is receiving treatment elsewhere, particularly when consideration is being given to compulsorily detain that individual”
3. delayed psychiatric assessment for worsening condition
“There should be a psychiatric assessment, by a Consultant [name redacted] in circumstances where there is a referral to the Home Treatment Team where a patient's condition has worsened”

Stated action

“a memo has been distributed to all clinical Staff in City and Hackney highlighting the issue”